Provider Demographics
NPI:1962825000
Name:MOYER, JOHNNY (NP)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:MOYER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:FOUR OAKS
Mailing Address - State:NC
Mailing Address - Zip Code:27524-0340
Mailing Address - Country:US
Mailing Address - Phone:910-567-6194
Mailing Address - Fax:910-567-5661
Practice Address - Street 1:341A WHITEVILLE RD NW
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-4507
Practice Address - Country:US
Practice Address - Phone:910-567-6194
Practice Address - Fax:910-567-5661
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5014809363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95000240Medicaid